C.O.P.E. CENTER, INC.

CHILD/ADOLESCENT BIO-PSYCHOSOCIAL SELF ASSESSMENT

C.O.P.E. Center, Inc. wishes to provide you with the best services possible. In order to do so we need to obtain the
following information. This information will be used to assign you to the most appropriate program or therapist. Your
assigned therapist will review this information with you to help develop your Treatment Plan.

Please be aware that this information is confidential with the following exceptions: (1) if you sign a Release of
Information form; (2) upon receipt of a court order by a judge; (3) in the event of a valid emergency; (4) if you commit a
crime at the program or against any person at the program, or threaten to commit such a crime; or (5) upon suspicion of
abuse or neglect; (6) upon receipt of a request that may be governed by Florida Statutes, such as Workers Compensation.
If there is information you don’t wish to write down, explain to your therapist during interview.

Unless otherwise noted, all questions should be answered regarding the person who will be receiving services (for
example: your child). If more space is needed, continue responses on back of page. Thank you for your assistance.

Name of person to receive services: ___________________________________________

Date of Birth: ____________ Sex: _________ Social Security #: ___________________
Other names used: _________________________________________________________
Who referred you to treatment? __Self __Dept. Children & Families __Parents
__Family member __Physician __School __Work __Other, specify: ______________
Who has Legal Custody of Child? ____________________________________________
Name(s) and relationship(s) of persons providing assessment information: _____________
_________________________________________________________________________
Are you willing and able to participate in client services when appropriate? Yes No
Comments: ________________________________________________________________

PRESENTING PROBLEM

Describe specifically the mental, emotional, and/or behavioral problems the Child is
currently experiencing. Include how often; how long: ______________________________
__________________________________________________________________________
__________________________________________________________________________
History of the problems (Describe age and circumstances when problems began):
________________________________________________________________________________
________________________________________________________________________________
Issues important to you/child: ________________________________________________
_________________________________________________________________________

PAST MENTAL HEALTH TREATMENT

Has the Child ever been in the hospital for mental health treatment? Yes No
Has the Child ever been in outpatient care for mental health treatment? Yes No
Has the Child ever been in an in-school treatment program? Yes No
Has the Child ever been in a residential treatment center? Yes No

Client Name: _________________________________ #: ____________________ Page 1 of 10

COPE Form # 1102-12 (Dev. 9/01 Rev. 3/02, 9/02, 8/03, 3/05, 11/05,01/06, 02/09, 10/10, 01/11, 02/11)
 Name of Facility Location Reason for Treatment Start/End Dates How did child do?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Was treatment completed? Yes No

Did Child have a positive experience in previous treatment? Yes No
Was Child compliant with treatment recommendations? Yes No
Comments regarding treatment history: _________________________________________
_________________________________________________________________________

Do you feel that the child is at risk for dangerous behaviors? Yes No
What situations increase the risk for dangerous behaviors? ______________________
__________________________________________________________________________
What does child do to cope with these risks? _____________________________________
__________________________________________________________________________
Describe any warning signs for the dangerous behaviors: ____________________________
__________________________________________________________________________

EDUCATIONAL / DAYCARE HISTORY

Current school: _______________________________________ Current Grade: _______

Current daycare: ___________________________________________________________

History of:
Academic Problems: Yes No Academic Strengths: Yes No
If yes, explain: _________________________________________________________
Has Child been retained? Yes No
If yes, explain: _________________________________________________________
Behavior Problems: Yes No
If yes, explain: _________________________________________________________
Educational Evaluations: Yes No
If yes, explain: _________________________________________________________
Special Education Placement: Yes No
If yes, explain: _________________________________________________________

EMPLOYMENT HISTORY

Has the Child had any Vocational training? Yes No

Describe: ______________________________________________________________
Has the Child had any Vocational problems? Yes No
Describe: ______________________________________________________________
Has the Child ever worked? Yes No
Describe: ______________________________________________________________

SOCIAL RESOURCES

Is the Child able to form and maintain relationships with family/friends? Yes No
Client Name: _________________________________ #: ____________________ Page 2 of 10
COPE Form # 1102-12 (Dev. 9/01 Rev. 3/02, 9/02, 8/03, 3/05, 11/05,01/06, 02/09, 10/10, 01/11, 02/11)
 Peer relationships: _________________________________________________________
________________________________________________________________________
What are the Child’s favorite activities: ________________________________________
________________________________________________________________________
Hobbies and interests: ______________________________________________________
________________________________________________________________________
Does the child have a Girlfriend or Boyfriend: Yes No
Current problems with close relationships? Yes No
Describe: ______________________________________________________________

Sexually active: Yes No

Describe: ______________________________________________________________

Gang involvement: Yes No

Describe: ______________________________________________________________

LEGAL HISTORY OF CHILD/ADOLESCENT

If history of legal issues, please explain:

_________________________________________________________________________
_________________________________________________________________________
Arrest charges pending: Yes No
Describe: ______________________________________________________________
Previous arrests: Yes No
Describe: ______________________________________________________________
Probation: Yes No
Describe: ______________________________________________________________
Court supervision: Yes No
Describe: ______________________________________________________________
Family court/status offenses: Yes No
Describe: ______________________________________________________________
Restitution: Yes No
Describe: ______________________________________________________________

DEVELOPMENTAL HISTORY

Were there complications with the pregnancy? Yes No

Describe: ______________________________________________________________
Did mother sustain any major injury/illness while pregnant? Yes No
Describe: ______________________________________________________________
Did mother use tobacco, alcohol, street drugs or prescription drugs during pregnancy?
Yes No
Describe: ______________________________________________________________
Was the delivery premature or overdue? Yes No
Describe: ______________________________________________________________
Were the complications with the labor/delivery? Yes No
Describe: ______________________________________________________________

DEVELOPMENT
Client Name: _________________________________ #: ____________________ Page 3 of 10
COPE Form # 1102-12 (Dev. 9/01 Rev. 3/02, 9/02, 8/03, 3/05, 11/05,01/06, 02/09, 10/10, 01/11, 02/11)
 Gross motor development: Early Average Delayed Don’t Know
Fine motor development: Early Average Delayed Don’t Know
Cognitive development: Early Average Delayed Don’t Know
Expressive communication: Early Average Delayed Don’t Know
Receptive communication: Early Average Delayed Don’t Know
Self-care (e.g., dressing, feeding, toileting):
Early Average Delayed Don’t Know
Social skills: Early Average Delayed Don’t Know
Comments: _______________________________________________________________
_________________________________________________________________________

INFANT TEMPERAMENT

Easy to comfort: Yes No

Quiet / aloof: Yes No
Excessive Irritability: Yes No
Overactive: Yes No
Describe early sleeping and feeding habits: ______________________________________
_________________________________________________________________________
_________________________________________________________________________

MEDICAL HISTORY

What is Child’s general health: Excellent Good Fair Poor

Describe: ______________________________________________________________
Immunization Record Current? Yes No
Any significant illnesses or injuries? Yes No
Describe: ______________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Any neuropsychological (brain) issues? Yes No
Explain any other medical issues; identify if issues are current or in the past:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

TRAUMATIC EVENTS

Current or past experience of being abused or neglected? Yes No

List: ____________________________________________________________________
Describe the above, or any other traumatic experience: ____________________________
________________________________________________________________________
Has the child received services for the past abuse? Yes No
If no, would you be interested in receiving services? Yes No

MEDICATIONS

Has Child taken any medications in the past two weeks? Yes No
Client Name: _________________________________ #: ____________________ Page 4 of 10
COPE Form # 1102-12 (Dev. 9/01 Rev. 3/02, 9/02, 8/03, 3/05, 11/05,01/06, 02/09, 10/10, 01/11, 02/11)
 Has Child taken any medications for any reason? Yes No
Was Child compliant with medications in the past? Yes No

Medications Taken (List All):

Name Dosage Reason Prescribed and Date Reason Ended and Date
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
List any other medication not included above:
________________________________________________________________________________
________________________________________________________________________________

SUBSTANCE ABUSE HISTORY

Does the Child have a history of substance abuse? Yes No

Describe: ______________________________________________________________
_________________________________________________________________________

Drugs or Alcohol Used (by preference, with #1 being most preferred):

Drug? How Taken? Age Started? Frequency of use? Most Recent Use?
1.______________________________________________________________________________
2.______________________________________________________________________________
3.______________________________________________________________________________
4.______________________________________________________________________________
5.______________________________________________________________________________
6.______________________________________________________________________________

Does the Child currently live with a person using substances? Yes No
Has the Child been exposed to substance abuse? Yes No

Does the Child use tobacco products? Yes No

Describe: ______________________________________________________________

OTHER ADDICTIONS (Pornography, video games, internet, gambling, etc.)? Yes No

Describe: _______________________________________________________________
__________________________________________________________________________

PSYCHOSOCIAL HISTORY

Are there family issues that need to be addressed in treatment? Yes No

Does the child have a positive relationship with parents? Yes No
Does the child have a positive relationship with siblings? Yes No

Current living situation, history, and information about the child’s family. May include
cultural, religious, income, housing information, other agencies involved, and family
relationships. ______________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Client Name: _________________________________ #: ____________________ Page 5 of 10
COPE Form # 1102-12 (Dev. 9/01 Rev. 3/02, 9/02, 8/03, 3/05, 11/05,01/06, 02/09, 10/10, 01/11, 02/11)
 Are there any cultural issues that could interfere with treatment? Yes No
Describe: _______________________________________________________________
__________________________________________________________________________

Is there current DCF (HRS) involvement? Yes No

Has there been past DCF (HRS) involvement? Yes No
Describe: _______________________________________________________________
__________________________________________________________________________

CURRENT LIVING SITUATION

Is child in need of food, clothing, or shelter? Yes No
Describe: _______________________________________________________________
__________________________________________________________________________
Current living arrangement: ___________________________________________________
__________________________________________________________________________
Number of persons, other than the Child, currently living in the home? ________

LIST HOUSEHOLD MEMBERS

Name? Relationship? Date of Birth/Age? Address? Phone?
1._______________________________________________________________________________
2._______________________________________________________________________________
3._______________________________________________________________________________
4._______________________________________________________________________________
5._______________________________________________________________________________
6._______________________________________________________________________________

Living environment (condition of the home): Good In need of repair N/A

How many times has the Child’s residence changed within the last two years? ______
Explain: ________________________________________________________________
__________________________________________________________________________

How would you rate the family’s Socioeconomic Position:

__Well Above Average __Above Average __Average __Below Average __Well Below
Average

Do you possibly qualify for public assistance? Yes No Unknown

What are the Child’s current support systems:_____________________________________

__________________________________________________________________________
Describe: _______________________________________________________________

CHILD’S STRENGTHS
List: _____________________________________________________________________
_________________________________________________________________________
CHILD’S ABILITIES
List: _____________________________________________________________________
_________________________________________________________________________
CHILD’S/FAMILY’S PREFERENCES
List: _____________________________________________________________________
_________________________________________________________________________
Client Name: _________________________________ #: ____________________ Page 6 of 10
COPE Form # 1102-12 (Dev. 9/01 Rev. 3/02, 9/02, 8/03, 3/05, 11/05,01/06, 02/09, 10/10, 01/11, 02/11)
 PAST SIGNIFICANT EVENTS (Check any of the following that apply):
__Significant medical condition of parent/caregiver
__Medical condition of child
__Post-partum adjustment problems of mother
__Mental illness of parent/caregiver
__Substance abuse of parent/caregiver
__Separation/divorce of parent/caregiver
__Adoption
__Abandonment of significant adult caregiver
__Death of parent/caregiver
__Mental retardation of parent/caregiver
__Incarceration of parent/caregiver
Comments: ________________________________________________________________
__________________________________________________________________________

Has the Child ever lived in any of the following settings? Yes No
__Relative’s home __Foster family __Orphanage
__Group home __Therapeutic foster care __Halfway house
__Emergency shelter __Correctional facility __Residential substance abuse facility
__Detention facility __Homeless __Hospital
__Other __Residential treatment center

Comments: ________________________________________________________________
__________________________________________________________________________

Most restrictive living situation in last 3 months:

__________________________________________________________________________

SPIRITUAL CONSIDERATIONS
Primary religious affiliation: ___________________________________________________

Does Child have spiritual strengths? Yes No

Does Child have spiritual problems? Yes No
Describe: _______________________________________________________________
__________________________________________________________________________

Have any family members had a history of Mental Illness: Yes No

If so, describe illness (give diagnosis if known): __________________________________
__________________________________________________________________________
Family History of Substance Abuse? ____________________________________________
__________________________________________________________________________
Family History of Criminal Activity? ____________________________________________
__________________________________________________________________________
Family History of Violent Behavior? ____________________________________________
__________________________________________________________________________
Family History of Medical Problems?____________________________________________
__________________________________________________________________________

Client Name: _________________________________ #: ____________________ Page 7 of 10

COPE Form # 1102-12 (Dev. 9/01 Rev. 3/02, 9/02, 8/03, 3/05, 11/05,01/06, 02/09, 10/10, 01/11, 02/11)
 STOP HERE PLEASE

Client Name: _________________________________ #: ____________________ Page 8 of 10

COPE Form # 1102-12 (Dev. 9/01 Rev. 3/02, 9/02, 8/03, 3/05, 11/05,01/06, 02/09, 10/10, 01/11, 02/11)
 INDIVIDUALIZED RECOVERY PLAN
(TENTATIVE)

What are the client’s goals and preferences for treatment? Will there be family involvement?
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________

Problems Identified How Problem is to be Addressed (Indicate if deferred and why)

1. _______________________________________________ __________________________________________________________

2. _______________________________________________ __________________________________________________________

3. _______________________________________________ __________________________________________________________

4. _______________________________________________ __________________________________________________________

Identified educational needs: (Include where and how these needs will be addressed): _________________________________________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

Barriers to Treatment Identified: (check only those that apply)

__Educational limitations __Developmental delays __Lacking Economic Resources __Low Motivation
__Unemployment __Transportation __ Physical Problems __Homelessness
__Limited Family/Social Support __Limited Insight
__Other _______________________________________________________________________________________________________

Treatment Services/Modalities Recommended: (Include service, modality, and frequency. Include external referral):
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________

Criteria for Discharge:

_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________

_______________________________________________ _____________________________________________________
Client (or Guardian) Signature/Date Clinician Signature/Credentials//Date
I understand the purpose of this Treatment Plan. I was, and will
continue to be, involved in decisions regarding my treatment.

_______________________________________________
Qualified Professional/Supervisor/ Signature/Credentials/Date
The diagnosis and treatment recommendations have been reviewed and
appear to be appropriate given the individual’s condition at this time.

Client Name: _________________________________ #: ____________________ Page 9 of 10

COPE Form # 1102-12 (Dev. 9/01 Rev. 3/02, 9/02, 8/03, 3/05, 11/05,01/06, 02/09, 10/10, 01/11, 02/11)
Client Name: _________________________________ #: ____________________ Page 10 of 10
COPE Form # 1102-12 (Dev. 9/01 Rev. 3/02, 9/02, 8/03, 3/05, 11/05,01/06, 02/09, 10/10, 01/11, 02/11)